BioMed Central Page 1 of 2 (page number not for citation purposes) Journal of Occupational Medicine and Toxicology Open Access Case report Appendectomy due to lead poisoning: a case-report S Mohammadi* 1 , AH Mehrparvar 2 and M Aghilinejad 1 Address: 1 Department of Occupational Medicine and Occupational Medicine Research Center of Iran University of Medical Sciences, Shaheed Hemmat highway, Tehran, Iran and 2 Department of Occupational Medicine, Yazd University of Medical Sciences, Yazd, Iran Email: S Mohammadi* - sabermohammadi@gmail.com; AH Mehrparvar - Ah.mehrparvar@gmail.com; M Aghilinejad - Dr.maghilinejad@yahoo.com * Corresponding author Abstract Background: Lead poisoning is a common occupational health hazard in developing countries and many misdiagnoses and malpractices may occur due to unawareness of lead poisoning symptoms. Case presentation: We report a case of occupational lead poisoning in an adult battery worker with abdominal colic who initially underwent appendectomy with removal of normal appendix. Later on he was diagnosed with lead poisoning and was treated appropriately with lead chelator (CaNa 2 EDTA). Conclusion: Lead poisoning is frequently overlooked as the differential diagnosis of acute abdomen which may result in unnecessary surgery. Appropriate occupational history taking is helpful in making a correct diagnosis. Occupational lead poisoning is a preventable disorder and a serious challenge for the health and labor authorities in developing countries. Background Lead is present in trace amounts in all soils, water, and foods. Currently, lead is used in more than 900 industries, including mining, smelting, refining, battery manufactur- ing, soldering, and so on. [1] Lead toxicity today is recognized as a major environmen- tal health risk, with the most serious effects in young chil- dren. [1] But owing to insufficient controlling measures in work places, lead poisoning is yet a common occupa- tional health hazard in developing countries and many misdiagnoses and malpractices can occur due to unaware- ness of lead poisoning as an imitator of many organ symptoms. [2] Case-report Our patient is a 41 year-old married male (with 3 chil- dren, the eldest being 7) living in Tehran. His medical his- tory did not show any other disease or hospitalization. He is a heavy smoker (about 30 pack-year). He has been working as an operator of a machine used to cut and fin- ish lead plates for 14 years in a battery-manufacturing plant. He used to work in a lead smelting plant for 2 years before his current job. He has had severe abdominal colic since 4 months ago. He was admitted in a hospital with the diagnosis of appendicitis and underwent an appendectomy operation (pathology revealed normal tissue of appendix) without any improvement in symptoms. He has also had other symptoms including headache, lethargy, fatigue, irritabil- ity, insomnia, muscle pain (especially in the legs), consti- Published: 17 October 2008 Journal of Occupational Medicine and Toxicology 2008, 3:23 doi:10.1186/1745-6673-3-23 Received: 27 June 2006 Accepted: 17 October 2008 This article is available from: http://www.occup-med.com/content/3/1/23 © 2008 Mohammadi et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Publish with BioMed Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp BioMedcentral Journal of Occupational Medicine and Toxicology 2008, 3:23 http://www.occup-med.com/content/3/1/23 Page 2 of 2 (page number not for citation purposes) pation, decreased libido, nausea, vomiting, tremor, loss of appetite, and weight loss. After discharge from hospital without any improvement, he was referred to occupational medicine clinic of Tehran University of Medical Sciences with suspicion of lead intoxication by an occupational medicine specialist who was in charge of medical examinations of the workers in that plant. When we visited him, he had the aforementioned abdom- inal pain. Upon physical examination he was afebrile (37.2°C oral) with respiratory rate of 14/min and pulse rate of 82/min. His blood pressure was 145/90 mmHg. His conjunctivae were pale; he had a mild tenderness in deep abdominal palpation and a surgery scar on his right lower quadrant. Blood test revealed a blood lead level of 118 μg/dl. However, he didn't have any other symptoms such as lead lines or symptoms related to neuropathy. The results of other laboratory tests are as follows: Three months after appearance of symptoms: WBC 6.8 × 10 3 , RBC 4.3 × 10 6 , Hb 10.9, Hct 35.1, MCV 80.1, MCH 24.9, MCHC 31.1, PLT 255 × 10 3 . One month later (after admission): Hb 9.7, Hct 29.8, MCV 81, MCH 26.4, MCHC 32.5. He was treated with continuous IV infusion of CaNa 2 - EDTA 1 g Bid for 5 days. During treatment his renal func- tion was evaluated on a daily basis. After starting the treat- ment his symptoms improved and he was discharged from hospital. After 2 weeks his blood lead level was 38.3 μg/dl. Upon complete recovery he returned to his job at his former workplace. Discussion Lead intoxication is highly prevalent among persons chronically over-exposed to lead. Symptoms include arthralgia, myalgia, headache, weakness, depression, loss of libido, impotence, and vague gastrointestinal prob- lems. [3] The first gastrointestinal symptoms begin to appear at blood lead level around 80 μg/dl. They consist of loss of appetite, digestive disturbances, epigastric dis- comfort after meals, and either constipation or diarrhea. When the blood lead level exceeds 100 μg/dl, the likeli- hood of more severe symptoms increases. These include occasional or frequent abdominal colic and severe consti- pation. If exposure does not stop, classic lead colic devel- ops [4], which often results in inappropriate laparatomy. [5] In our country, the main sources of occupational lead poi- soning are battery-manufacturing plants, lead smelting plants, and steel plants. We do not have any specific limit values and use ACGIH-TLVs as regulatory measures for blood lead (50 μg/dl in two occasions needs removal from work). Our patient worked in a battery-manufacturing plant and had typical symptoms and signs of lead poisoning; he was also inappropriately operated for appendicitis. Lead intoxication symptoms such as abdominal pain, constipation, nausea, vomiting, etc make this disease an important diagnosis to be differentiated from many gas- trointestinal and surgical diseases, and the significant point is that lead intoxication is preventable and its treat- ment is straightforward. Therefore, paying attention to a good occupational history will prevent many unnecessary and/or avoidable medical interventions. Competing interests The authors declare that they have no competing interests. Authors' contributions SM and AHM contributed in visiting the case, MA contrib- uted in editing the manuscript, all authors contributed in drafting the manuscript, all authors read and approved the final manuscript. Consent Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent (in Persian) is available for review by the Editor- in-Chief of this journal. References 1. Habal R: Lead toxicity. [http://www.emedicine.com/MED/ topic1269.htm]. 2. ILO Encyclopedia of Occupational Health and Safety, Lead, 63.19; Geneva 4th edition. 1998, III:. 3. Moline JM, Landrigan JP: Lead. In Text book of Clinical Occupational and Environmental Medicine 2nd edition. Edited by: Rosenstock L, Cullen MR, Brodkin CA, Redlich CA. ELSEVIER Inc; 2005:967-78. 4. Saryan LA, Zenz C: Lead and its compounds. In Occupational Med- icine 3rd edition. Edited by: Zenz C. USA: Mobsy; 1994:506-548. 5. Kehoe RA: Occupational lead poisoning: Chemical signs of the absorption of lead. J Occup Med 1972, 14(5):390-396. . countries and many misdiagnoses and malpractices can occur due to unaware- ness of lead poisoning as an imitator of many organ symptoms. [2] Case-report Our patient is a 41 year-old married male (with. underwent appendectomy with removal of normal appendix. Later on he was diagnosed with lead poisoning and was treated appropriately with lead chelator (CaNa 2 EDTA). Conclusion: Lead poisoning. Tehran, Iran and 2 Department of Occupational Medicine, Yazd University of Medical Sciences, Yazd, Iran Email: S Mohammadi* - sabermohammadi@gmail.com; AH Mehrparvar - Ah.mehrparvar@gmail.com;